Is access to intensive care equitable?

Challenging the logic of lifesaving in the intensive care unit

Intensive care units are considered life-saving medical services and a vital component of healthcare systems. These specialized hospital wards contain the life support machines and technical expertise to sustain seriously ill and injured bodies. However, as the COVID-19 pandemic has demonstrated, intensive care is an expensive, finite resource which is not necessarily available to all citizens, and which may be unjustly rationed. As a result, the intensive care unit may contribute more towards biopolitical narratives of investment in lifesaving than measurable improvements in population health. Drawing from ethnographic fieldwork and a decade of involvement in clinical research, this paper examines everyday activities of lifesaving in the intensive care unit and interrogates epistemological assumptions upon which they are organized. A closer look at how healthcare professionals, medical devices, patients, and families accept, refuse, and modify imposed boundaries of bodily finitude reveals how activities of lifesaving often lead to uncertainty and may even impose harm when they deny possibilities for desired death. Refiguring death as a personal ethical threshold, rather than inherently tragic ending, challenges the power of the logic of lifesaving and instead insists on greater attention towards improving conditions for living.

Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care

BACKGROUND

Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making.

METHODS

Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80 years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback-Leibler divergence with regard to withholding or withdrawing decisions.

RESULTS

Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback-Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree.

CONCLUSIONS

Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required.

TRIAL REGISTRATION

VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).

Association between immigrant status and advanced cancer patients' location and quality of death

Background

Cancer patients often prefer to die at home, a location associated with better quality of death (QoD). Several studies demonstrate disparities in end‐of‐life care among immigrant populations in the United States. This study aimed to evaluate how immigrant status affects location and quality of death among patients with advanced cancer in the United States.

Methods

Data were derived from Coping with Cancer, a federally funded multi‐site prospective study of advanced cancer patients and caregivers. The sample of patients who died during the study period was weighted (N_w = 308) to reduce statistically significant differences between immigrant (N_w = 49) and nonimmigrant (N_w = 259) study participants. Primary outcomes were location of death, death at preferred location, and poor QoD.

Results

Analyses adjusted for covariates indicated that patients who were immigrants were more likely to die in a hospital than home (adjusted odds ratio [AOR], 3.33; 95% confidence interval [CI], 1.65–6.71) and less likely to die where they preferred (AOR, 0.42; 95% CI, 0.20–0.90). Furthermore, immigrants were more likely to have poor QoD (AOR, 5.47; 95% CI, 2.70–11.08).

Conclusions

Immigrants, as compared to nonimmigrants, are more likely to die in hospital settings, less likely to die at their preferred location, and more likely to have poor QoD.

Lay summary

Cancer patients typically prefer to die in their own homes, which is associated with improved quality of death.

However, disparities in end‐of‐life care among immigrant populations in the United States remain significant.

Our study found that immigrants are less likely to die in their preferred locations and more likely to die in hospital settings, resulting in poorer quality of death.

Disparities in end‐of‐life care and quality of death are prevalent among immigrants. The findings of this study illustrate that immigrants in the United States are more likely to die in hospital settings and less likely to die at their preferred location.